Analysis of factors affecting discharge with the personal consent of hospitalized patients: A cross‐sectional study

Abstract Background and Aims Discharge by personal satisfaction is a condition in which the patient leaves the hospital before completing the care period against medical advice. Thus, this study aims to identify and analyze the reasons for discharge with the personal satisfaction of hospitalized patients. Methods The study was descriptive‐analytical being performed in 2021. The study population was 2869 discharged inpatients with personal satisfaction. Sampling was done by random and census. The data were collected using a checklist and a researcher‐made questionnaire whose validity and reliability were confirmed. The data were analyzed using SPSS24 by K‐Score test for qualitative and variance for quantitative variables. Results The discharge rate by personal satisfaction was 7.01%, the average age was 42 years, and the average length of stay was 4 days. Further, 57.1% of patients were female, 63.7% were married, and 21% were babies. A total of 22.77% of the patients were discharged with the father's consent, of which 13.2% were re‐admitted. The most common reasons for the discharge were feeling of recovery (47.2%), the hospital being educational (30%), and dissatisfaction with the services of doctors (51.6%). Discharge with personal satisfaction had a significant relationship with the length of hospitalization (p < 0.001) and type of hospital (p = 0.04). Conclusion The feeling of recovery, the educational nature of the hospital, and dissatisfaction with the services of doctors were the most common reasons for discharge with personal satisfaction. Therefore, monitoring the provision of services, establishing proper patient‐doctor communication, and increasing the awareness of patients and parents could reduce this type of discharge and its consequences.


| INTRODUCTION
Nowadays, retaining customers in the healthcare system has become more difficult to the past since the increased number of organizations providing medical services, on the one hand, and the increased awareness of medical issues and quality care, on the other hand, offer applicants a wider range of choices. Therefore, in the competition arena, an organization will be more successful if it makes more efforts to satisfy its customers. 1 The health system aims to produce health by providing services to patients. For this reason, if there is no trust in the service provider organizations, the health sector will lose its identity. Indeed, patient satisfaction with medical care is a measure of his/her understanding of the care quality. 2 Satisfaction is the basis for choosing a healthcare facility in the future by the patient or recommending it to other patients. Patient dissatisfaction also leads to poor care cooperation, causing a waste of resources and decreasing the quality of care. Therefore, trying to obtain patient satisfaction should be one of the important goals of healthcare organizations. One of the problems that may arise due to patient dissatisfaction with the services received is discharge with personal consent, indicating the existence of a significant issue. 3 This ultimately causes the stagnation of work and the poor financial condition of the centers, irreparably damaging them 4 with increased costs and decreased income. 5 Self-satisfied discharge refers to a condition in which the patient is discharged before completing the course of care against medical advice. 2,5,6 There is great variation in the discharge rate by personal consent from one country to another. Approximately 1%-2% of all hospital discharges in the United States are personal. 7 Also, this rate has been reported as 4% in Saudi Arabia, 0.72% in Nigeria, and 10.3% in Iran. 8 In addition to the problems it creates for the hospital, the type of discharge is also an important issue for the patient and healthcare providers 8 because it leads to adverse health outcomes, rehospitalization, illness, and death. [7][8][9][10] According to research, the rate of rehospitalization in the first 2 weeks after discharge in patients with personal consent is higher than in those discharged with a doctor's order. 2,9 The rehospitalization rate in such patients increases since their condition at home is worsened, or the therapeutic process is disrupted. 11 This rate in Canada is 10% 1 and, in the United States, it is between 0.8% and 2.2%, 12 while in Iran, it is 3% in people with a mental health condition and 20% in the emergency department. 11 The goal of a health system is to ensure the health of people in a society. To achieve this, it must provide desirable services; the desirability of such services is evaluated by monitoring and controlling them. One method to assess health services is to investigate the level of satisfaction of patients. The reason for the great tendency of health researchers to investigate and analyze the factors affecting patient satisfaction is determined according to these points and the number of studies in this field in different countries and years. These studies in different volumes and designs had variable results; however, their common result, patient satisfaction with the discharge, has the opposite relationship with personal desire. 13 Malekzadeh et al., 6 in a cross-sectional descriptive study, investigated the status of discharge by personal consent. Based on their results, the most common reasons for such discharge were relative recovery, lack of trust in the quality of hospital services, and emotional motives. 6 Ghorbinia and Moradi 5 descriptively analyzed the causes of discharge by personal consent. In their study, the discharge rate was 8.69%, the most common reason was the feeling of recovery, and there was a statistical relationship between such discharge with marital status and type of insurance. Ashrafi et al. 11 investigated discharge with personal satisfaction, besides its causes and predictive factors. In this research, the most common cause of the discharge was personal problems and going to other centers.
Based on this study, to reduce the rate of discharge with the satisfaction of the person, it is required to create a suitable environment, provide appropriate services, and meet the needs of patients and companions. 11 Self-directed discharge is a multi-dimensional category and includes several factors. 2 Identifying these factors is very important to recognize those more likely to have this type of discharge.
Accordingly, it is possible to inform people about its consequences, which prevents this process, thus reducing the rate of rehospitalization and mortality. Therefore, this study aimed to identify and analyze the causes of discharge with personal satisfaction in hospitalized patients.

| METHODS
The study was descriptive-analytical and done cross-sectionally Hazrat Masoumeh 66). In Imam Reza (a.s.) hospital, simple random sampling was used due to high statistics, while, in other hospitals, the census method was applied due to low statistics. The data were collected using a checklist and a researcher-made questionnaire.
The validity of the checklist and questionnaire was confirmed by the opinion of 10 experts (three information management specialists, four nurses, and three physicians), and the reliability of the questionnaire was confirmed by Cronbach's alpha of 85%.
The checklist included five sections of patient information, disease, hospital and doctor, insurance, and para-clinical services.
Data were collected by preparing a list of discharged patients with personal consent, extracting their records from the hospital information system, and studying the records. A questionnaire was used to collect data on the reasons for self-directed discharge, which consisted of two parts: the first included satisfactory characteristics, patient demographic information, and admission and discharge times, and the second included reasons related to the patient (10 reasons), hospital (6 reasons), and service providers (7 reasons).
To collect the data for this section, the phone/mobile number of the patient and companion were retrieved from the system; then, the patient was contacted first, and by introducing him/herself, the reason for discharge was asked with personal consent. If they did not answer or did not know because they were elderly, children, or disabled, the companion was asked. Data were analyzed using (SPSS24 software), descriptive statistics, mean, standard deviation, and analysis of variance. The significance level was considered at 0.05.

| RESULTS
In this study, discharge with personal consent was investigated in four hospitals (two general and two neonatal hospitals) related to the University of Medical Sciences and Social Security in Kermanshah.
The research findings showed that the total discharge rate with personal satisfaction was 7.01%, 8.86% for the University of Medical Sciences, 0.86% for social security, 10.66% for general, and 0.6% for newborns. The discharge rate with personal consent in the University of Medical Sciences general hospital was 10.98%, while it was 1.66% for social security. Also, the rate of discharge with the personal consent of newborns in the hospital of the University of Medical Sciences was 0.35%, while it was 0.77% for social security.
The average age of the patients was 42 years, and the average length of stay was 4 days. The largest number of patients, with 57.1%, were women. Further, 63.7% were married, and 21% were babies. Additionally, 28.1% had less education than a diploma, 21.8% had a diploma, and 17.5% were illiterate, while people with higher education, i.e., master's degree and above, were 1.7%. Housewives, with 41.3%, were the most, and students, with 3%, were the least discharged patients with personal consent. Also, 86.5% had no underlying disease.
A total of 22.77% of the patients were discharged with the father's consent, followed by the son and the wife (20.79%). Most of these patients were admitted on Saturday (16.8%) and fewer on Thursday (11.9%); also, 42.6% were admitted in the morning, and 59.4% were discharged in the morning. Additionally, 13.2% of patients discharged by personal consent were re-admitted.
In this study, the reasons for discharge with personal satisfaction were investigated for three cases related to service providers (personnel and doctors), patients, and hospitals. For personal reasons related to the patient, feeling better (47.2%) was the most common, and being a traveler and not having a companion were the least reasons (1.2%) (Tables 1 and 2).
For factors related to the hospital, being educational was the highest reason, with 30% (Table 3). For reasons related to healthcare providers, lack of satisfaction with doctor services (51.6%) and nursing services (18.8%) were the highest, while disrespect to the patient or companion (1.6%) was the lowest reason (Table 4).

| DISCUSSION
Nowadays, with information technologies, awareness of healthcare facilities and their quality has increased, making it possible to be compared. The number of patients who leave the hospital with personal satisfaction indicates issues that need attention. In addition, discharge with personal consent leads to increased costs, loss of working days, disability, or even death for patients. 14 Therefore, in today's competitive world, to attract and increase customers, it is necessary for hospitals to continuously investigate the reasons for discharge by personal consent and complaints, thus solving problems and improving the conditions in the future.
The overall rate of discharge by personal satisfaction was 7.01. It has been reported between 0.8% and 2.2% in American hospitals, while it is 1.8%, 1.1%, and 4.2% in England, Canada, and Nigeria, respectively. In Iran, this rate is between 3% in Psychiatric hospitals, varying up to 20% in emergency departments. 15 The discharge rate by personal consent in hospitalized patients of Kashan University of Medical Sciences is 10.3%, Tehran University of Medical Sciences is 7.17%, and Boali Children's Hospital in Sari is 22%. 16 In this study, the average age of the patients was 42 years, and the average length of stay was 4 days. The largest number of patients T A B L E 3 Frequency of hospital-related personal discharge reasons.

Hospital reasons Frequency Percent
The oldness of the hospital 1 5 The educational nature of the hospital 6 30 Hospital facilities 2 10 The hospital dirtiness 5 25 Overcrowding and high density of patients 3 15 Lack of para-clinical facilities and equipment 3 15 by the father, and 17.7% were re-hospitalized. They said that it was because the treatment process was not completed.
Considering that the study is related to children and the discharge was done with the father's consent, full justification of the parents is necessary to make the right decision. 15 In Kamaluddin's study, 15% 20 and, in Asadi's study, 9.06% of patients were readmitted 15 days after discharge with personal consent. 21 Two hospitals in this study were related to children, the age and legal condition of whom were such that they were allowed to be treated and discharged by their parents; thus, about 30% were discharged with the father's consent. Therefore, it is necessary to give training and counseling to parents about the consequences of personal consent discharge.
Reasons for discharge by personal consent were investigated for three cases related to healthcare providers, patients, and hospitals.
For patient-related reasons, the feeling of recovery was the most on the other hand, they had to leave the hospital with their consent to earn money for the family. There was a significant relationship between discharge with personal satisfaction and length of hospitalization (p < 0.001), patient's problems, and the type of hospital (p = 0.04).

| CONCLUSION
The most common reason for discharge with personal satisfaction was related to the patient (the feeling of recovery 47.2%), the hospital (being educational 30%), and the staff (dissatisfaction with the doctor's services 51.3%). Therefore, the feeling of recovery before the completion of the care period makes the patient think he/ she is better and can be discharged. Also, in teaching hospitals, patients are dissatisfied due to the treatment of patients by medical students and less presence of specialists. In addition, the advice of specialists to refer patients to private hospitals to receive more wages causes dissatisfaction with the doctor's services. Therefore,

| STUDY LIMITATION
Hospital information systems have a section to record the reason for discharge with personal consent by nurses. Unfortunately, the discharge with personal consent was recorded, but the main reason was not. In this study, to find the main reason for discharge with personal consent, patients or their companions were contacted.
Some were not available, did not answer, or had forgotten the main reason, which was one of the limitations of the study.